January 2017 Reading Notes

Each month, I come across papers expressing ideas that are new, complex, and difficult to digest in one sitting. Nevertheless, I try, and here are the fruits of my efforts. I figure if I take some notes, I might have something to build on in the future.

Donating Stock to Charity

Argument: The ACA has done some good. Fact: ACA expanded insurance coverage so that a larger percentage of the US population is now insured than ever in its history. Obama's Perspective: This represents financial security and better health. My Perspective: As a young healthy adult above the age of 26 currently in medical school living in New York State, Medicaid expansion means I save roughly ~$5000/year (about how much a student health insurance plan costs) because I can get Medicaid coverage (which is free). Without much money in my bank accounts, this is definitely some financial security for me. Am I in better health? No, because I never find time to see the doctor anyway.

Obama suggests: Allow Medicare to negotiate drug prices to bring down prescription drug prices. I wonder: Is this even remotely within the realm of possibility given the strength of the pharmaceutical industry in the US? And given the fact that the US is the only country where pharmaceutical companies generate the necessary revenue to fund the R&D + Quality Control that make modern medicine as reliable as it is? Are my assumptions about the position of the pharmaceutical industry correct?

Obama's Main Concern: Repealing the ACA before laying out some replacement/amending legislation would result in uncertainty and harm. Exhibit A: Insurance companies will raise prices to avoid blame for any unpopular changes. (I don't get this one...) Exhibit B: Stopping investment in care coordination if Medicare's Innovation Center is eliminated (eh... maybe. I do know that investment in this stuff is pretty fragile just judging based on how people talk about it) Exhibit C: "Hospitals may have to cut back services and jobs in the short run in anticipation of the surge in uncompensated care that will result from rolling back the Medicaid expansion." (This is where stuff gets scary for me in terms of harm done. In my experience within a large academic medical center, hospitals don't have great profit margins and even the ones that do make money go through great pains to minimize amount of charity care provided to patients who could never afford the care. Practices like turfing patients from one emergency department to another or simply delays in service due to cutting staff seem very realistic to me because I know the need for care definitely outstrips the supply in many urban settings. Speaking as someone who works on clinical care teams nearly everyday, I know that having one less person on staff can make a difference in clinical workflow that could lead to patient harm.)

Obama Notes: "Congress can take a responsible, bipartisan approach to improving the health care system. This was how we overhauled Medicare’s flawed physician payment system less than 2 years ago." Most Compelling Sentence To Me: "I will applaud legislation that improves Americans’ care, but Republicans should identify improvements and explain their plan from the start — they owe the American people nothing less." (Yeah... I like explanations. Who doesn't? Also, please don't take away my Medicaid.)

Ultimately, overuse can be considered to occur along a continuum. At one end of the continuum lie tests and treatments that are universally beneficial when used on the appropriate patient, such as blood cultures in a young, otherwise healthy patient with sepsis, and insulin for patients with type 1 diabetes. At the other end of the continuum are services that are entirely ineffective, futile, or pose such a high risk of harm to all patients that they should never be delivered, such as the drug combination fenfluramine-phentermine for obesity.